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APPLICATION FOR PERMIT _ <br /> SAN .fOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA - <br /> s Telephone (209) 466-6781 <br /> -PERMIT EXPIRES TYEAR FROM DATE ISSUED >< <br /> (Complete in Triplicate) <br /> tication is <br /> it scribe ' his app• f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h i ; <br /> made a compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and ` � RBgulati,oit the San Joaquin <br /> .;� <br /> Local Health District. �0.N`- � <br /> L V CJ a � C�eilr .f� City�� . PM <br /> Job Address <br /> (�/f/iF w`Address Phone G� <br /> Owner's Name <br /> �p/3� Phone2f-?142r3 <br /> Contractor. <br /> Iv(if�At v►� �G� Address License No <br /> TYPE OF WELL/PUMP: NEW WELL- WELL REPLACEMENT El DESTRUCTION ❑ <br /> REPAIR ❑ OTHER <br /> SYSTEM C3PUMP INSTALLATION^B ` <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI D rJ <br /> Dia. of Well Casing v j <br /> 'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation [ <br /> / Type of Casing Specifications <br /> ❑ Domestic)Private ,8 Grav_el_Pack ❑ Tracy j- Type of Grout <br /> t"1 Public / IOth-er �/frdY(l Delta Depth of Grout Seal <br /> I 1 Irrigation _Apprax. Depth I I Eastern S!ace Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> (Uhl" H.P. —_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing aterial (top 501 - m <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 RFPAIR/ADDITION l ] DESTRUCTION l I afvailablewit in 200 fee <br /> septic <br /> t jed it public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: (1 <br /> Capacity No. Compartments <br /> 4 SEPTIC TANK ❑ Type/Mfg Method of Disposal <br />` PKG. TREATMENT PLT. ❑ <br /> Distance•to nearest: Well ' Foundation Property.Line <br /> �1 <br /> Total length/size <br /> LEACHING LINE C1No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> e Number <br /> SEEPAGE PITS � l I Depth Size Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ardina�,�C��laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. r's <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for.which this�� `co' tr , Is hall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiri { .su <br /> certifies the following: I certify that in th performance of the work for which this permit is issued, I shall employ pers�rs�6ject t cwt% en's compensa <br /> g: ,• J <br /> tion laws of California." <br /> The applicant call fo ed inspections. Complete drawing on re arse side. <br /> Date: <br /> Signed X Title: Q` ®��`� a�,• <br /> FOR DEPAR MENT USE ONL <br /> Application Accepted by <br /> Date —f Area <br /> Date 10 Final Inspection by Date��` <br /> Pit or Grout inspection by <br /> Additional Comments: ld� <br /> LJStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 - ❑ Tracy 835- 5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> CYC PERMIT'N <br /> FEE RECEIVED BY DATE O. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> • a.EH13.241REV.Iin5) <br /> EH 14-2a <br />